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Cordoba A, El Hajj H, Escande A, Scouarnec C, Narducci F, Martinez Gomez C, Leblanc E, Hudry D, Pasquesoone C, Taieb S, Mirabel X, Lartigau EF, Le Tinier F. Intermediate-risk endometrial cancer treated with adjuvant brachytherapy using single dosimetric planning: long-term outcome and toxicity assessment. Eur J Obstet Gynecol Reprod Biol 2024; 298:23-30. [PMID: 38705010 DOI: 10.1016/j.ejogrb.2024.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/22/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE Brachytherapy of the vaginal dome is the recommended adjuvant treatment for intermediate-risk endometrial cancer. This study assessed the results of dosimetric planning of high-dose-rate brachytherapy exclusively in the first treatment session. STUDY DESIGN This retrospective study included all patients who underwent hysterectomy for endometrial cancer followed by adjuvant brachytherapy of the vaginal dome between 2012 and 2015. Local recurrence rates, overall survival (OS) rates, recurrence-free survival (RFS) rates, and related acute and late toxicity rates were evaluated. RESULTS This analysis included 250 patients, of whom 208 were considered to be at high-intermediate risk of disease recurrence. After a median follow-up of 56 months, the cumulative incidence of local recurrence was 4.8% at 3 years [95% confidence interval (CI) 2.8-8.3] and 7.8% at 5 years (95% CI 4.8-12.6). The 5-year OS rate was 86.2% (95% CI 80.6-90.3), and the 5-year RFS rate was 77.5% (95% CI 71.1-82.7). Acute toxicity occurred in 20 (8%) patients, of which two patients had grade ≥3 toxicity. Only one patient (0.4%) presented with late grade ≥3 toxicity. CONCLUSION These findings confirm the tolerability of this brachytherapy approach, indicating minimal cases of late grade ≥3 toxicity, associated with a good 5-year OS rate. With the advent of molecular prognostic factors, the current focus revolves around discerning those individuals who gain the greatest benefit from adjuvant therapy, and tailoring treatment more effectively.
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Affiliation(s)
- Abel Cordoba
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Cancer Centre, Lille, France.
| | - Houssein El Hajj
- Department of Surgical Oncology, Oscar Lambret Cancer Centre, Lille, France
| | - Alexandre Escande
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Cancer Centre, Lille, France
| | - Cyrielle Scouarnec
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Cancer Centre, Lille, France
| | - Fabrice Narducci
- Department of Surgical Oncology, Oscar Lambret Cancer Centre, Lille, France
| | | | - Eric Leblanc
- Department of Surgical Oncology, Oscar Lambret Cancer Centre, Lille, France
| | - Delphine Hudry
- Department of Surgical Oncology, Oscar Lambret Cancer Centre, Lille, France
| | | | - Sophie Taieb
- Department of Medical Imaging, Oscar Lambret Cancer Centre, Lille, France
| | - Xavier Mirabel
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Cancer Centre, Lille, France
| | - Eric F Lartigau
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Cancer Centre, Lille, France
| | - Florence Le Tinier
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Cancer Centre, Lille, France
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Hsieh K, Bloom JR, Dickstein DR, Shah A, Yu C, Nehlsen AD, Resende Salgado L, Gupta V, Chadha M, Sindhu KK. Risk-Tailoring Radiotherapy for Endometrial Cancer: A Narrative Review. Cancers (Basel) 2024; 16:1346. [PMID: 38611024 PMCID: PMC11011021 DOI: 10.3390/cancers16071346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Endometrial cancer is the most common gynecologic cancer in the United States and it contributes to the second most gynecologic cancer-related deaths. With upfront surgery, the specific characteristics of both the patient and tumor allow for risk-tailored treatment algorithms including adjuvant radiotherapy and systemic therapy. In this narrative review, we discuss the current radiation treatment paradigm for endometrial cancer with an emphasis on various radiotherapy modalities, techniques, and dosing regimens. We then elaborate on how to tailor radiotherapy treatment courses in combination with other cancer-directed treatments, including chemotherapy and immunotherapy. In conclusion, this review summarizes ongoing research that aims to further individualize radiotherapy regimens for individuals in an attempt to improve patient outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Rios-Doria E, Cun HT, Filippova OT, Mueller JJ, Alektiar KM, Ellenson LH, Makker V, Lakhman Y, Leitao MM, Jhingran A, Soliman PT, Abu-Rustum NR. Isolated vaginal recurrence in women with stage I endometrial cancer. Gynecol Oncol 2023; 179:9-15. [PMID: 37864854 PMCID: PMC11215939 DOI: 10.1016/j.ygyno.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE To compare clinical and pathologic characteristics of women with surgical stage I endometrial carcinoma by location of first recurrence and describe characteristics of isolated vaginal recurrence. METHODS Patients with 2009 International Federation of Obstetrics and Gynecology (FIGO) stage I endometrial carcinoma treated at two large cancer centers from 1/1/2009-12/31/2017 were identified. Sarcoma histology was excluded. Recurrences were grouped into isolated vaginal or extravaginal. Isolated vaginal recurrences were localized by anatomic location within the vaginal vault. Clinical and pathologic variables were compared with chi-square analysis, and Kaplan-Meier curves with log-rank tests. RESULTS Of 2815 women identified, 278 (10%) experienced a recurrence. Sixty-one patients (2%) had an isolated vaginal recurrence, including 42 (69%) at the vaginal apex; 217 (8%) had an extravaginal recurrence, including 18 with a vaginal component. Median time to recurrence was 11 months (range, 1-68) for isolated vaginal recurrence and 20 months (range, 1-98) for extravaginal recurrence (P < .004). Of 960 patients (34%) treated with adjuvant vaginal brachytherapy (VBT), 156 (16%) recurred; 19 (2%) had an isolated vaginal recurrence, including 16 (84%) at the vaginal apex. Three-year PFS rates for isolated vaginal recurrence were 97.6% (SE ± 0.4%) with minimally invasive surgery (MIS) versus 96.9% (SE ± 1.1%) with open (P = .8), and for extravaginal recurrence were 91.8% (SE ± 0.7%) with MIS versus 90.8% (SE ± 1.8%) with open (P = .8). CONCLUSIONS Isolated vaginal recurrences in stage I endometrial cancer are detected earlier than non-vaginal recurrences. Surgical approach does not appear to impact recurrence. Adjuvant VBT after primary surgery carries a 1%-2% risk of isolated vaginal apex recurrence.
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Affiliation(s)
- Eric Rios-Doria
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Han T Cun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Olga T Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jennifer J Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lora H Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vicky Makker
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Yulia Lakhman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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Noorian F, Abellana R, Zhang Y, Herreros A, Baltrons C, Lancellota V, Tagliaferri L, Sabater S, Torne A, Rovirosa A. Are 7.5 Gy×2 fractions more efficient than 6 Gy×3 in exclusive postoperative endometrial cancer brachytherapy? A clinical and dosimetrical analysis. Radiother Oncol 2023; 189:109909. [PMID: 37699447 DOI: 10.1016/j.radonc.2023.109909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE To compare two vaginal brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) patients considering vaginal-cuff relapses (VCR), late toxicities, dosimetry analysis and vaginal dilator use. MATERIAL AND METHODS 110 PEC patients were treated with exclusive high-dose-rate VBT using two schedules. Group-1:44-patients received 6 Gy×3fractions (September-2011-April-2014); Group-2:66-patients were treated with 7.5 Gy×2fractions with a dose limit of equivalent total doses in 2-Gy fr (EQD2(α/β=3)) of 68 Gy in the most exposed 2 cm3 of clinical target volume (CTV) (July-2015-November-2021). The dose was prescribed at 5 mm from the applicator surface. Were evaluated the overall radiation dose delivered to 90% of the CTV (D90), the CTV receiving 100% of the prescription dose (V100) and the EQD2(α/β=3) received in the most exposed 2 cm3 to dose in CTV. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum and objective LENT-SOMA criteria for late vaginal toxicity (LVT). STATISTICS Descriptive analysis, Chi-square, Student's t-tests and Kaplan and Meier method. RESULTS The median follow-up was 60 months (15.9-60). There were no VCR or late toxicities in bladder or rectum. LVT ≥ G1 appeared in 26/44 (59.1%) in Group-1 and 25/66 (37.9%) in Group-2. The mean EQD2(α/β=3) received by the most exposed 2 cm3 of CTV was 63.7 Gy ± 10.0 in Group-1 and 60.5 Gy ± 3.8 in Group-2 (p = 0.063). There were no differences in adherence to vaginal dilator use ≥9 months, overall D90 and V100. CONCLUSION Considering the lack of vaginal relapses and similar LVT over time, 7.5 Gy×2fractions seem more efficient in terms of patient comfort, workload, and cost. This is the first study using dosimetry parameters to compare effectivity of schedules. Larger series are needed to confirm the present results.
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Affiliation(s)
- Faegheh Noorian
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Rosa Abellana
- Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Yaowen Zhang
- Cancer Center, Henan Provincial People's Hospital, No.7 Weiwu Road, Zhengzhou 450003, China.
| | - Antonio Herreros
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Clara Baltrons
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain.
| | - Vallentina Lancellota
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy.
| | - Luca Tagliaferri
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy.
| | | | - Aureli Torne
- Gynecological Cancer Unit, Hospital Clinic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain.
| | - Angeles Rovirosa
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
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5
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Kunz JN, Huang YJ, Casper AC, Suneja G, Burt LM, Jhingran A, Joyner MM, Harkenrider MM, Small W, Grant JD, Kidd EA, Boucher K, Gaffney DK. Dosimetric Evaluation of Organs at Risk From SAVE Protocol. Int J Radiat Oncol Biol Phys 2023; 117:274-280. [PMID: 37023988 DOI: 10.1016/j.ijrobp.2023.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/26/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE The objective of this work was to evaluate dosimetric characteristics to organs at risk (OARs) from short-course adjuvant vaginal cuff brachytherapy (VCB) in early endometrial cancer compared with standard of care (SOC) in a multi-institutional prospective randomized trial. METHODS AND MATERIALS SAVE (Short Course Adjuvant Vaginal Brachytherapy in Early Endometrial Cancer Compared to Standard of Care) is a prospective, phase 3, multisite randomized trial in which 108 patients requiring VCB were randomized to an experimental short-course arm (11 Gy × 2 fractions [fx] to surface) and SOC arm. Those randomized to the SOC arm were subdivided into treatment groups based on treating physician discretion as follows: 7 Gy × 3 fx to 5 mm, 5 to 5.5 Gy × 4 fx to 5 mm, and 6 Gy × 5 fx to surface. To evaluate doses to OARs of each SAVE cohort, the rectum, bladder, sigmoid, small bowel, and urethra were contoured on planning computed tomography, and doses to OARs were compared by treatment arm. Absolute doses for each OAR and from each fractionation scheme were converted to 2 Gy equivalent dose (EQD23). Each SOC arm was compared with the experimental arm separately using 1-way analysis of variance, followed by pairwise comparisons using Tukey's honestly significant difference test. RESULTS The experimental arm had significantly lower doses for rectum, bladder, sigmoid, and urethra compared with the 7 Gy × 3 and 5 to 5.5 Gy × 4 fractionation schemes; however, the experimental arm did not differ from the 6 Gy × 5 fractionation scheme. For small bowel doses, none of the SOC fractionation schemes were statistically different than the experimental. The highest EQD23 doses to the examined OARs were observed to come from the most common dose fractionation scheme of 7 Gy × 3 fx. With a short median follow-up of 1 year, there have been no isolated vaginal recurrences. CONCLUSIONS Experimental short-course VCB of 11 Gy × 2 fx to the surface provides a comparable biologically effective dose to SOC courses. Experimental short-course VCB was found to reduce or be comparable to D2cc and D0.1cc EQD23 doses to rectum, bladder, sigmoid, small bowel, and urethra critical structures. This may translate into a comparable or lower rate of acute and late adverse effects.
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Affiliation(s)
- Jeremy N Kunz
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anthony C Casper
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Lindsay M Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anuja Jhingran
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Melissa M Joyner
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Center, Intermountain Health Care, Murray, Utah
| | - Elizabeth A Kidd
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Ken Boucher
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Wernicke AG, Parashar B, Samuel E, Sabbas A, Gupta D, Caputo T. Partial-Length Treatment With Brachytherapy in Patients With Endometrial Cancer With High-Risk Features Is as Effective as Full-Length Vaginal Brachytherapy but With Reduced Toxicity. Pract Radiat Oncol 2023; 13:e416-e422. [PMID: 37295725 DOI: 10.1016/j.prro.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Full-length vaginal (FLV) brachytherapy for patients with endometrial cancer and high-risk features should be considered as per the American Brachytherapy Society to reduce distal vaginal recurrence in patients with endometrial cancers with papillary serous/clear cell histologies, grade 3 status, or extensive lymphovascular invasion. We sought to investigate this patient population and report outcomes of treatment with high-dose-rate (HDR) brachytherapy in women treated with FLV brachytherapy versus partial-length vaginal (PLV) brachytherapy. METHODS AND MATERIALS With institutional review board approval, we identified patients with endometrial cancer meeting American Brachytherapy Society criteria of high-risk features treated with adjuvant HDR between 2004 and 2010. HDR doses were 21Gy in 3 fractions delivered to either the full-length or partial-length vagina. Acute and late toxicities were evaluated using the Radiation Therapy Oncology Group scale and Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer grading, respectfully. Vaginal recurrences were assessed by physical examination and pap smears. Statistical analyses were performed using SPSS version 23 software. RESULTS Of 240 patients treated with HDR brachytherapy, 121 were treated with FLV brachytherapy, and 119, with PLV brachytherapy. The median follow-up was 9.5 years (range, 8-11 years) for FLV patients and 8.5 years (range, 7-10 years) for PLV patients; 0% of patients had vaginal recurrences, and 1.4% and 0.9% had proximal vaginal recurrences, respectively (P = .54). All patients treated with FLV brachytherapy developed grade 3 mucositis of the lower vagina/introitus (P < .0001) and had increased analgesics use compared with those treated with PLV brachytherapy (P < .0001). In total, 23% of patients treated with FLV brachytherapy developed grade 3 stenosis of the lower vagina/introitus, in contrast to 0% of patients treated with PLV brachytherapy (P < .0001). CONCLUSIONS PLV brachytherapy is as effective as FLV brachytherapy in reducing local recurrence and causes a significantly lower incidence of acute and late toxicities. The results of this study caution radiation oncologists regarding the careful use of FLV brachytherapy in patients with endometrial cancer and high-risk features.
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Affiliation(s)
- A Gabriella Wernicke
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York; Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York.
| | - Bhupesh Parashar
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Eileen Samuel
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Albert Sabbas
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York
| | - Divya Gupta
- Senior Group Medical Directory, GlaxoSmithKline, Waltham, Massachusetts
| | - Thomas Caputo
- Department of Obstetrics and Gynecology, Division of Gynecological Oncology, Weill Medical College of Cornell University, New York, New York
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Wang W, Wang T, Liu Z, He J, Sun X, Zhong W, Zhao F, Li X, Li S, Zhu H, Ma Z, Hu K, Zhang F, Hou X, Wei L, Zou L. Practice patterns of adjuvant radiotherapy in women with stage I to II endometrial carcinoma: a real-world multi-institutional analysis in China. BMC Womens Health 2023; 23:417. [PMID: 37553639 PMCID: PMC10410771 DOI: 10.1186/s12905-023-02548-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 07/14/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND This study aimed to report clinical practice patterns of postoperative radiotherapy for stage I to II endometrial carcinoma (EC) patients treated in 13 Chinese medical centers. METHODS We included early stage EC patients treated by hysterectomy and adjuvant RT between 2003 and 2017 from 13 institutions. Patients were classified into 4 risk groups based on ESMO-ESGO-ESTRO recommendations (2014). RESULTS A total of 1,227 cases were analyzed. Along the 15 years of the study, an increasing tendency was found towards administration for vaginal brachytherapy (VBT) alone, while the proportion of external beam pelvic radiotherapy (EBRT) alone remained stable in the corresponding period. When radiation modalities were stratified by risk groups, proportion of VBT alone significantly increased in all risk groups. The higher the risk, the later VBT became the main adjuvant treatment modality. However, EBRT alone or with VBT remained the main adjuvant method for high-risk patients. There were 13 dose-fractionation schemes for VBT alone with the scheme of 30 Gy in 6 fractions prescribed at 0.5cm under the vaginal mucosa accounting for most. There were 17 schemes for VBT boost and the most common schedule was 10 Gy in 2 fractions. The upper 3-5cm part of vagina was the most frequent target. 89.6% of the practitioners performed two-dimensional VBT technique. The median dose for EBRT was 50 Gy. From 2003 to 2017, conventional radiotherapy was gradually replaced by three-dimensional conformal radiotherapy modality and intensity modulated radiotherapy. CONCLUSION We report a significant shift from EBRT to VBT alone for high-intermediate-risk, intermediate-risk and low-risk EC patients from 2003 to 2017 while EBRT remained the main radiation modality for high-risk early stage patients. There has been remarkable heterogeneity among VBT dose fractionation schedules across China. TRIAL REGISTRATION The clinical trial ID was ChiCTR-PRC-17010712. It was authorized by the Institutional Review Board of Peking Union Medical College Hospital (N0. S-K139).
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Affiliation(s)
- Wenhui Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tiejun Wang
- Department of Radiation Oncology, The Second Hospital Affiliated By Jilin University, Changchun, People's Republic of China
| | - Zi Liu
- Department of Radiation Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Jianli He
- Department of Radiation Oncology, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China
| | - Xiaoge Sun
- Department of Radiation Oncology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, People's Republic of China
| | - Wei Zhong
- Gynaecological Oncology Radiotherapy, The Affiliated Cancer Hospital of Xinjiang Medical University, Urumqi, People's Republic of China
| | - Fengjv Zhao
- Department of Radiation Oncology, Gansu Provincial Cancer Hospital, Lanzhou, Gansu, People's Republic of China
| | - Xiaomei Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, People's Republic of China
| | - Sha Li
- Department of Radiation Oncology, The 940Th Hospital of Joint Logistics Support Force of Chinesc People's Liberation Army, Lanzhou, Gansu, People's Republic of China
| | - Hong Zhu
- Department of Radiation Oncology, Xiangya Hospital Central South University, Changsha, Hunan, People's Republic of China
| | - Zhanshu Ma
- Department of Radiation Oncology, Affiliated Hospital of Chi Feng University, Chifeng, Inner Mongolia, People's Republic of China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Lichun Wei
- Department of Radiation Oncology, Xijing Hospital, Air Force Medical University of PLA (the Fourth Military Medical University), Xi'an, People's Republic of China.
| | - Lijuan Zou
- Department of Radiation Oncology, The Second Hospital of Dalian Medical University, Dalian, People's Republic of China.
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Zeng Z, Lu Y, Zhang F, Zhang J, Zhang W, Luo C, Guo Y, Yan J, Yu L. Personalized Brachytherapy for a Herlyn-Werner-Wunderlich Syndrome Patient with Endometrial Cancer: A Case Report. Cancer Manag Res 2023; 15:691-697. [PMID: 37469374 PMCID: PMC10353564 DOI: 10.2147/cmar.s416366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023] Open
Abstract
Purpose Endometrial carcinoma (EC) is a common gynecological malignancy. Vaginal cuff brachytherapy (VBT) is an adjuvant treatment for EC. Since a single-channel cylinder sometimes delivers inadequate dose coverage to the vaginal apex, three-dimensional (3D) printing technology can be used to achieve satisfactory dose distribution. Here, we report the first case of an EC patient with Herlyn-Werner-Wunderlich syndrome (HWWS) treated with VBT using 3D-printed applicators. Case Presentation Here, we present a case study of an endometrial cancer patient with HWWS who underwent surgery. During adjuvant radiotherapy, 3D-printed applicators were used in VBT. To accomplish the reconstruction of the source pathways on magnetic resonance imaging, catheters with copper sulfate were placed in two 3D-printed applicators. The early tolerance of this treatment was positive. During the 6-month follow-up, locoregional recurrence was not detected. Conclusion Our findings strongly indicate that VBT with 3D-printed applicators may be a reasonable treatment option for EC with HWWS.
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Affiliation(s)
- Zheng Zeng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Yuanyuan Lu
- Department of Radiation Oncology, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, People’s Republic of China
| | - Fuquan Zhang
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People’s Republic of China
| | - Jie Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Wenjun Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Chunli Luo
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Yuping Guo
- Gynecological Radiotherapy Ward, The Third Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
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9
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Wallner K, Sherertz T, Anderson A, Blau M, Panjwani N. (Potential) mishaps of high dose rate vaginal cuff brachytherapy. Pract Radiat Oncol 2023:S1879-8500(23)00050-4. [PMID: 36889643 DOI: 10.1016/j.prro.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/05/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Considering how commonly vaginal cuff brachytherapy is used, there is relatively little literature regarding the potential, albeit low, risk for complications. We present here three potentially serious mishaps, involving cylinder misplacement, dehiscence, and excessive normal tissue irradiation due to unique anatomy. METHODS Three patients with potentially serious treatment errors were encountered in the authors' usual clinical practice. Each patient's records were reviewed for this report. RESULTS For patient #1, CT simulation revealed grossly inadequate cylinder insertion, most obvious on the sagittal view. For patient #2, CT simulation revealed that the cylinder extended beyond the perforated vaginal cuff and was surrounded by bowel. For patient #3, CT images were used only to verify cylinder depth. A standard library plan, based on cylinder diameter and active length was used. In retrospect, the images revealed an unusually thin rectovaginal septum, with the lateral and posterior vaginal wall thickness estimated to be less than 2 mm. Her fractional normal tissue doses were calculated for this report, revealing a rectal Dmax (per fraction) of 10.8 Gy, D2.0 of 7.4 Gy, and a V100 of 2.8 cc. All doses were far in excess of those anticipated for a minimal 0.5 cm vaginal wall depth. CONCLUSION Vaginal cuff HDR brachytherapy is a high volume, routine procedure. Even in experienced hands, however, it carries a risk of improper cylinder placement, cuff dehiscence, and excessive normal tissue dose, all of which could seriously impact outcomes. These potential mishaps would be better appreciated and avoided with more extensive use of CT-based quality assurance measures.
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Affiliation(s)
- Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Tracy Sherertz
- Department of Radiation Oncology, Kaiser Permanente, Seattle, WA
| | - August Anderson
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Molly Blau
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Neil Panjwani
- Department of Radiation Oncology, University of Washington, Seattle, WA
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10
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Harkenrider MM, Kamrava M. Embracing a future of progress in gynecologic brachytherapy. Brachytherapy 2023; 22:6-8. [PMID: 36725200 DOI: 10.1016/j.brachy.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 01/31/2023]
Abstract
In the last 20 years, gynecologic brachytherapy has made tremendous advancements, most prominently evidenced by the evolution of cervical cancer brachytherapy. In its 20 year history, Brachytherapy has become known as a journal of science, education, and advocacy for our specialty and for our patients. In this review, we celebrate the 25 most impactful manuscripts in gynecologic brachytherapy in the journal's history.
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Affiliation(s)
- Matthew M Harkenrider
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL.
| | - Mitchell Kamrava
- Cedars Sinai Medical Center, Department of Radiation Oncology, Los Angeles, CA
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11
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Harkenrider MM, Abu-Rustum N, Albuquerque K, Bradfield L, Bradley K, Dolinar E, Doll CM, Elshaikh M, Frick MA, Gehrig PA, Han K, Hathout L, Jones E, Klopp A, Mourtada F, Suneja G, Wright AA, Yashar C, Erickson BA. Radiation Therapy for Endometrial Cancer: An American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol 2023; 13:41-65. [PMID: 36280107 DOI: 10.1016/j.prro.2022.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE With the results of several recently published clinical trials, this guideline informs on the use of adjuvant radiation therapy (RT) and systemic therapy in the treatment of endometrial cancer. Updated evidence-based recommendations provide indications for adjuvant RT and the associated techniques, the utilization and sequencing of adjuvant systemic therapies, and the effect of surgical staging techniques and molecular tumor profiling. METHODS The American Society for Radiation Oncology convened a multidisciplinary task force to address 6 key questions that focused on the adjuvant management of patients with endometrial cancer. The key questions emphasized the (1) indications for adjuvant RT, (2) RT techniques, target volumes, dose fractionation, and treatment planning aims, (3) indications for systemic therapy, (4) sequencing of systemic therapy with RT, (5) effect of lymph node assessment on utilization of adjuvant therapy, and (6) effect of molecular tumor profiling on utilization of adjuvant therapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation. RESULTS The task force recommends RT (either vaginal brachytherapy or external beam RT) be given based on the patient's clinical-pathologic risk factors to reduce risk of vaginal and/or pelvic recurrence. When external beam RT is delivered, intensity modulated RT with daily image guided RT is recommended to reduce acute and late toxicity. Chemotherapy is recommended for patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to II with high-risk histologies and those with FIGO stage III to IVA with any histology. When sequencing chemotherapy and RT, there is no prospective data to support an optimal sequence. Sentinel lymph node mapping is recommended over pelvic lymphadenectomy for surgical nodal staging. Data on sentinel lymph node pathologic ultrastaging status supports that patients with isolated tumor cells be treated as node negative and adjuvant therapy based on uterine risk factors and patients with micrometastases be treated as node positive. The available data on molecular characterization of endometrial cancer are compelling and should be increasingly considered when making recommendations for adjuvant therapy. CONCLUSIONS These recommendations guide evidence-based best clinical practices on the use of adjuvant therapy for endometrial cancer.
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois.
| | - Nadeem Abu-Rustum
- Department of Gynecologic Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Kristin Bradley
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | | | - Corinne M Doll
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Melissa A Frick
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Paola A Gehrig
- Division of Gynecologic Oncology, University of Virginia, Charlottesville, Virginia
| | - Kathy Han
- Department of Radiation Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Ellen Jones
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Ann Klopp
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas Mourtada
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California, San Diego, California
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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12
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Parsons MW, Huang YJ, Burt L, Suneja G, Gaffney D. Vaginal cuff brachytherapy for endometrial cancer: a review of major clinical trials with a focus on fractionation. Int J Gynecol Cancer 2022; 32:311-315. [DOI: 10.1136/ijgc-2021-002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/03/2022] Open
Abstract
The use of vaginal cuff brachytherapy in the adjuvant management of endometrial cancer has increased over time. Recommendations from the American Brachytherapy Society, American Society of Radiation Oncology, and European Society for Medical Oncology help to guide the application of vaginal cuff brachytherapy. However, wide variation in practice remains regarding treatment techniques. This article reviews the use of vaginal cuff brachytherapy in the post-operative management of endometrial cancer. It covers risk stratification, treatment rationale, outcomes, and treatment planning recommendations with a specific focus on dose-fractionation regimens. The authors performed a thorough literature review of articles pertinent to the goals of this review. Also presented are early results of the Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared with Standard of Care (SAVE) trial of a two-fraction vaginal cuff brachytherapy regimen.Adjuvant vaginal cuff brachytherapy for early-stage endometrial cancer results in excellent disease control with minimal toxicity. The PORTEC-2 trial showed that vaginal cuff brachytherapy is non-inferior to external beam radiation for vaginal recurrence in patients at high-intermediate risk. Vaginal cuff brachytherapy may also be used as a boost following external beam radiation in combination with chemotherapy for high-risk histologies. Numerous techniques can be used for vaginal cuff brachytherapy, including various medical devices, dose-fractionation schedules, and treatment planning approaches. The early control results of the SAVE trial are promising and we are hopeful that this trial establishes two fraction regimens as a viable option for vaginal cuff brachytherapy.
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13
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Lancellotta V, Macchia G, Dinapoli N, Autorino R, Campitelli M, Nardangeli A, Salvati A, Fionda B, Casà C, Cornacchione P, Rovirosa A, Kovács G, Morganti AG, Ferrandina MG, Gambacorta MA, Tagliaferri L. EROS 2.0 study: evaluation of two interventional radiotherapy (brachytherapy) schedules for endometrial cancer: a comparison of late vaginal toxicity rates. LA RADIOLOGIA MEDICA 2022; 127:341-348. [PMID: 35092552 PMCID: PMC8960610 DOI: 10.1007/s11547-022-01455-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/03/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND To compare the late toxicity rates after two different high dose rate (HDR) adjuvant intravaginal interventional radiotherapy (IRT-brachytherapy) dose schedules in stage I-II endometrial cancer. METHODS Stage I-II patients with endometrial cancer treated with surgery (with or without lymphadenectomy) and adjuvant HDR-IRT between 2014 and 2020 were included in this analysis. Patients were treated with two schedules. In the first cohort (C1), 21 Gy were delivered in three weekly fractions (7 Gy) prescribed 0.5 cm from the applicator surface. In the second cohort (C2), 24 Gy were delivered in four weekly fractions (6 Gy). The clinical target volume was the upper third of the vagina for C1 and the upper 3 cm for C2. HDR-IRT technique and point prescription (5 mm depth from the applicator surface) were the same for all patients. Vaginal toxicity was scored according to the CTCAE 5.0 scale in terms of the presence versus absence of any toxicity grade. The correlation among toxicity and clinical covariates (age, lymphadenectomy, fractionation, stage) was tested by Pearson correlation test (univariate) and by logistic regression (multivariable). RESULTS 114 stage I and three stage II patients, median age 62 (range: 32-85) years, were included in this analysis. The mean follow-up was 56.3 months in C1 (40-76) and 20 months in C2 (8-42). Vaginal late toxicity was recorded in 40 and 15 patients in C1 and 2, respectively. Age, lymphadenectomy, and fractionation were significantly correlated with toxicity at univariate analysis (p value = 0.029, 0.006, and 0.002, respectively), while stepwise logistic regression confirmed only age and fractionation as significantly correlated parameters (p value = 0.02 and 0.001, respectively). Three-year local relapse-free, distant metastasis-free and cause-specific survival rates were 96.6%, 94.8%, and 99.1%, respectively. CONCLUSIONS This analysis showed lower vaginal late toxicity rate in C2 compared to C1.
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Affiliation(s)
- Valentina Lancellotta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Gabriella Macchia
- Gemelli Molise Hospital, Radiation Oncology Unit, Università Cattolica del Sacro Cuore, 86100, Campobasso, Italy.
| | - Nicola Dinapoli
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Rosa Autorino
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Maura Campitelli
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Alessia Nardangeli
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Alessandra Salvati
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Bruno Fionda
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Calogero Casà
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Patrizia Cornacchione
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
| | - Angeles Rovirosa
- Department of Radiation Oncology, Hospital Clinic i Universitari, Fonaments Clinics Department, University of Barcelona, 08036, Barcelona, Spain
| | - György Kovács
- Università Cattolica del Sacro Cuore, 00128, Roma, Italy
| | - Alessio Giuseppe Morganti
- Radiotherapy Center, IRCCS Azienda Ospedaliera Universitaria di Bologna, 40138, Bologna, Italy
- DIMES, Alma Mater Studiorum University of Bologna, 40138, Bologna, Italy
| | - Maria Gabriella Ferrandina
- Woman, Child and Public Health Department, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, Roma, Italy
| | - Maria Antonietta Gambacorta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, 00128, Rome, Italy
| | - Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00128, Rome, Italy
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14
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Nieto K, Levine B, Brown D, Lanier C, Carriere P, McGinnis H, Hines K, Greven K. Pilot study to assess sexual function, quality of life (QOL) and change in vaginal dimensions following vaginal brachytherapy (VBT). Brachytherapy 2022; 21:283-290. [DOI: 10.1016/j.brachy.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/02/2022]
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15
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Qin X, Zhang F, Hou X, Yu L, Yu L, Yan J, Qiu J. Efficacy and safety of a 3D-printed applicator for vaginal brachytherapy in patients with central pelvic-recurrent cervical cancer after primary hysterectomy. Brachytherapy 2021; 21:193-201. [PMID: 34980568 DOI: 10.1016/j.brachy.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/11/2021] [Accepted: 11/08/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE Intracavitary and/or interstitial brachytherapy is an integral component of the management of patients with central pelvic-recurrent cervical cancer after primary hysterectomy, and is typically delivered using conventional applicators. We investigated the efficacy and safety of three-dimensional (3D)-printed, customizable applicators for those patients. METHODS AND MATERIALS Twenty-six patients were treated with combination external beam radiotherapy and brachytherapy. Patients with lesions ≤1 and >1 cm before brachytherapy were treated with intracavitary and interstitial brachytherapy, respectively. Dosimetric plans were compared between the vaginal cylinder and 3D-printed applicator for the first 9 patients. Outcomes and treatment-related complications were also investigated. RESULTS The median tumor size before brachytherapy was 0.81 cm. Intracavitary, interstitial, and combined interstitial-intracavitary brachytherapy were performed in 22 (85%), 3 (11%), and 1 (4%) of the patients, respectively. The clinical target volume (CTV) coverage goal was achieved with all 3D-printed plans but failed with three single-channel cylinder plans (33.3%). Owing to 3D-printed transvaginal applicator guidance, there was no need to adjust the needle position after implantation. The mean CTV dose for all patients was 71 ± 8.2 Gy; all met the dose constraints to the organs at risk, but 1 (4%) had a rectal D2cc overdose. The 2-year local control, progression-free survival, and overall survival rates were 87.8%, 71.0%, and 91.6%, respectively. Four patients (21%) developed early grade 3-4 hematological toxicities and 1 (4%) developed a late grade 3 adverse event. CONCLUSIONS High-quality intracavitary and/or interstitial brachytherapy can be achieved using a 3D-printed applicator and yields favorable outcomes with acceptable toxicity.
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Affiliation(s)
- Xue Qin
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lihua Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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16
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Arden JD, Dokter J, Almahariq MF, Marvin K, Nandalur SR, Al-Wahab Z, Gadzinski J, Rosen B, Jawad MS. Toxicity and Efficacy After Adjuvant Vaginal Brachytherapy Using 30 Gy in 6 Fractions for Stages I and II Endometrial Cancer. Adv Radiat Oncol 2021; 6:100773. [PMID: 34934859 PMCID: PMC8655421 DOI: 10.1016/j.adro.2021.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose This study aimed to evaluate outcomes and toxicity in patients with endometrial cancer per our institutional adjuvant vaginal cuff brachytherapy (VBT) fractionation scheme. Methods and Materials We identified women with International Federation of Gynecology and Oncology stages I and II endometrial cancer who underwent surgical staging and adjuvant high-dose-rate VBT without external beam radiation. All patients received 30 Gy in 6 fractions to the upper one-third of the vagina, prescribed to a depth of 5 mm and delivered twice weekly. Toxicities were prospectively elicited at each follow up, and rates of recurrence and survival were retrospectively assessed. Results We identified 247 eligible patients treated between 1992 and 2018 with a median follow up of 5.8 years (range, 0.1-24.7 years). Most patients had stage I disease (52% stage IA; 37% stage IB), and 11% of patients were stage II. Deep myometrial invasion was predictive of local recurrence (P = .002). The 5-year rates of local recurrence, regional recurrence, and distant metastases were 5%, 5%, and 7%, respectively. Five-year overall and disease-free survival were 91% and 83%, respectively. The most common grade 1 toxicities were acute fatigue (11% crude rate), urinary frequency (11%), chronic (>6 months) urinary frequency (13%), urinary incontinence (13%), and vaginal stenosis (21%). There were few grade 2 toxicities (all <5%) and no grade 3 to 5 toxicities. Conclusions The adjuvant VBT fractionation scheme of 30 Gy in 6 fractions results in low rates of toxicity, with no grade ≥3 adverse events, and local control rates comparable with those from other published series using different fractionation schemes.
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Affiliation(s)
- Jessica D Arden
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jonathan Dokter
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kimberly Marvin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sirisha R Nandalur
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid Al-Wahab
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jill Gadzinski
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Barry Rosen
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Maha Saada Jawad
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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17
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Zhang Y, Gomez G, Ascaso C, Herreros A, Fornes B, Mases J, Rochera J, Tagliaferri L, Sabater S, Torne A, Biete A, Rovirosa Á. Preliminary results of a vaginal constraint for reducing G2 late vaginal complications after postoperative brachytherapy in endometrial cancer: a prospective analysis. Clin Transl Oncol 2021; 24:875-881. [PMID: 34854030 PMCID: PMC9013320 DOI: 10.1007/s12094-021-02737-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
Abstract
Purpose To evaluate the preliminary results of the use of 68 Gy EQD2(α/β=3 Gy) as a dose limit to the lowest dose in the most exposed 2 cm3 of the vagina in order to reduce G2 late vaginal problems in postoperative endometrial carcinoma (EC).
Methods From November 2016 to October 2019, 69 postoperative EC patients receiving vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) were prospectively analyzed. The median EBRT dose was 45 Gy (range: 44–50.4 Gy), 1.8−2 Gy/day, 5 fractions(Fr)/week. VBT was administered with the following schedule: 1Fr of 7 Gy after EBRT and 2 daily Fr × 7.5 Gy in exclusive VBT. The dose was prescribed at 0.5 cm from the applicator surface with an active length of 2.5 cm; 56 patients were treated with vaginal cylinders (49–3.5 cm, 6–3 cm, and 1–2.5 cm) and 13 with the colpostat technique. The overall VBT dose was adjusted to meet the vaginal restriction of < 68 Gy EQD2(α/β=3 Gy) at 2 cm3. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum, and the objective LENT-SOMA criteria for vagina.
Results With a median follow-up of 31.0 months, no vaginal-cuff recurrences were found. Late toxicity: only 1G1(1.4%) rectal toxicity; 21G1(30.4%) and 3G2(4.3%) vaginal complications. Only one (1.4%) of 3 G2 manifested as vaginal shortening.
Conclusions In postoperative EC patients treated with VBT, only one developed G2 vaginal stenosis with the use of 68 Gy EQD2(α/β=3 Gy) as a dose constraint. These preliminary results seem to indicate the value of this dose limit for reducing G2 vaginal stenosis. Nonetheless, these findings should be confirmed in a larger number of patients with longer follow-up.
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Affiliation(s)
- Y Zhang
- Cancer Center, Henan Provincial People's Hospital, Zhengzhou, China
| | - G Gomez
- Radiation Oncology Dpt., Hospital Los Ángeles, Chihuahua, México
| | - C Ascaso
- Fonaments Clínics Dpt., Faculty of Medicine, Universitat de Barcelona, C/Casanovas 143, 08036, Barcelona, Spain
| | - A Herreros
- Fonaments Clínics Dpt., Faculty of Medicine, Universitat de Barcelona, C/Casanovas 143, 08036, Barcelona, Spain.,Radiation Oncology Dpt., Hospital Clinic Barcelona, Barcelona, Spain
| | - B Fornes
- Radiation Oncology Dpt., Hospital Clinic Barcelona, Barcelona, Spain
| | - J Mases
- Radiation Oncology Dpt., Hospital Clinic Barcelona, Barcelona, Spain
| | - J Rochera
- Radiation Oncology Dpt., Hospital Clinic Barcelona, Barcelona, Spain
| | - L Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - S Sabater
- Radiation Oncology Dpt., Hospital General Universitario de Albacete, Albacete, Spain
| | - A Torne
- Gynecological Cancer Unit, Hospital Clinic Barcelona, Barcelona, Spain
| | - A Biete
- Fonaments Clínics Dpt., Faculty of Medicine, Universitat de Barcelona, C/Casanovas 143, 08036, Barcelona, Spain.,Radiation Oncology Dpt., Hospital Clinic Barcelona, Barcelona, Spain.,Gynecological Cancer Unit, Hospital Clinic Barcelona, Barcelona, Spain
| | - Á Rovirosa
- Fonaments Clínics Dpt., Faculty of Medicine, Universitat de Barcelona, C/Casanovas 143, 08036, Barcelona, Spain. .,Radiation Oncology Dpt., Hospital Clinic Barcelona, Barcelona, Spain. .,Gynecological Cancer Unit, Hospital Clinic Barcelona, Barcelona, Spain.
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A comparison between 2D and 3D planning of high-dose-rate vaginal cuff brachytherapy in patients with stage I-II endometrial cancer using cobalt-60. J Contemp Brachytherapy 2021; 13:526-532. [PMID: 34759977 PMCID: PMC8565635 DOI: 10.5114/jcb.2021.110312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose Post-surgery radiation can reduce the risk of loco-regional relapse in high-intermediate-risk endometrial cancer. High-dose-rate vaginal cuff brachytherapy (HDR-BRT) is an acceptable method of radiation in majority of endometrial cancer cases. Although 2D planning is frequently used for treatment based on physical examination without any imaging, measurement of the dose received by organs-at-risk (OARs) is not possible. Therefore, the present study was the first to compare dose delivered to target and OARs in 2D vs. 3D planning in patients treated with cobalt-60 source. Material and methods In this study, organs including vagina wall, bladder, rectum, and sigmoid were contoured on computed tomography (CT) scan images of 37 endometrial cancer patients, and doses delivered to organs were recorded. Statistics, such as D90, D99, V100, V150, V200, D0.1cc, D1cc, and D2cc were determined. Results D90 and D99 were lower in 3D treatment planning in comparison with 2D. Although V100 was more in 3D planning, V150 and V200 were less. Analyzing D0.1cc, D1cc, and D2cc of OARs revealed that doses given to rectum, sigmoid, and bladder were less in 3D planning compared to 2D. Conclusions Comparison of 2D and 3D planning results showed that 3D planning could deliver an appropriate dose to the target while sparing more OARs.
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Harkenrider MM, Albuquerque K, Brown D, Kamrava M, King M, Mourtada F, Orio P, Patel R, Price M, Rassiah P, Solanki AA, Small W, Schechter NR. ACR-ABS-ASTRO practice parameter for the performance of radionuclide-based high-dose-rate brachytherapy. Brachytherapy 2021; 20:1071-1082. [PMID: 34588143 DOI: 10.1016/j.brachy.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE This practice parameter aims to detail the processes, qualifications of personnel, patient selection, equipment, patient and personnel safety, documentation, and quality control and improvement necessary for an HDR brachytherapy program. METHODS AND MATERIALS This practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO). RESULTS Brachytherapy is a radiotherapeutic modality in which radionuclide or electronic sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. Brachytherapy alone or combined with external beam radiotherapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides, such as iridium-192, at dose rates of ≥12 Gy/hr to a designated target point or volume, and it is an important treatment for a variety of malignant and benign conditions. Its use allows for application of high doses of radiation to defined target volumes with relative sparing of adjacent critical structures. CONCLUSIONS HDR brachytherapy requires detailed attention to personnel, equipment, patient and personnel safety, and continuing staff education. Coordination between the radiation oncologist and treatment planning staff and effective quality assurance procedures are important components of successful HDR brachytherapy programs.
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Affiliation(s)
| | - Kevin Albuquerque
- UT Southwestern Medical Center, Simmons Comprehensive Cancer Center, Dallas, TX
| | | | | | - Martin King
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | - Peter Orio
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | - Michael Price
- Columbia University Irving Medical Center, New York, NY
| | - Prema Rassiah
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - William Small
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Naomi R Schechter
- Keck Medical Center of USC, Norris Comprehensive Cancer, Center, University of Southern California, Los Angeles, CA
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Jensen GL, Barry PN, Eldredge-Hindy H, Silva SR, Todd SL, Hammonds KP, Zimmerman WR, Metzinger DS, El-Ghamry MN. Vaginal cuff brachytherapy: do we need to treat to more than a two-centimeter active length? J Contemp Brachytherapy 2021; 13:294-301. [PMID: 34122569 PMCID: PMC8170526 DOI: 10.5114/jcb.2021.105971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/09/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE American Brachytherapy Society (ABS) guidelines recommend using a 3-5 cm active length (AL) when treating vaginal cuff (VC) in adjuvant setting of endometrial cancer (EC). The purpose of this study was to evaluate local control and toxicity, using an AL of 1 or 2 cm and immobilization with a traditional table-mounted (stand) or patient-mounted (suspenders) device. MATERIAL AND METHODS Between 2005 and 2019, 247 patients with EC were treated with adjuvant high-dose-rate vaginal cuff (HDR-VC) brachytherapy with or without external beam radiation (EBRT). Treatment was prescribed to a 0.5 cm depth, with an AL of 1 or 2 cm, using stand or suspenders. VC boost after EBRT was typically administered with 2 fractions of 5.5 Gy, while VC brachytherapy alone was typically applied with 3 fractions of 7 Gy or 5 fractions of 5.5 Gy. RESULTS The combination of suspender immobilization and an AL of 2 cm (n = 126, 51%) resulted in 5-year local control of 100%. An AL of 2 cm compared to 1 cm correlated with better local control (99.1% vs. 88.5%, p = 0.0479). Regarding immobilization, suspenders correlated with improved local control compared to stand (100% vs. 86.7%, p = 0.0038). Immobilization technique was significantly correlated with AL (p < 0.0001). Only 5 (2.0%) patients experienced grade ≥ 3 toxicity, all of whom received EBRT. CONCLUSIONS In the present series, an AL of 2 cm provided excellent local control, while 1 cm was inadequate. Suspender immobilization was a practical alternative to stand immobilization in HDR brachytherapy of the vaginal cuff.
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Affiliation(s)
- Garrett L. Jensen
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
| | - Parul N. Barry
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women’s Hospital, Pittsburgh, USA
| | - Harriet Eldredge-Hindy
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Scott R. Silva
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Sarah L. Todd
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | | | - Walker R. Zimmerman
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
| | - Daniel S. Metzinger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Moataz N. El-Ghamry
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
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21
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Vaginal cuff brachytherapy practice in endometrial cancer patients: a report from the Turkish Oncology Group. J Contemp Brachytherapy 2021; 13:152-157. [PMID: 33897788 PMCID: PMC8060958 DOI: 10.5114/jcb.2021.105282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/22/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The American Brachytherapy Association is attempting to develop standards for delivering brachytherapy, although differences in practice have been reported in the literature. This study evaluated vaginal cuff brachytherapy (VBT) practice and quality of life-related recommendations among Turkish radiation oncologists. Material and methods A nationwide web-based 17-item survey was distributed to the members of the Turkish Society for Radiation Oncology. These members received e-mail notifications, and a link was posted on the Turkish Society for Radiation Oncology internet site to solicit voluntary responses The survey addressed the simulation processes, target volume, prescribed dose, delivery schedules, and recommendations related to vaginal side effects. Results Fifty-seven radiation oncologists responded to the survey. The most used dose fraction schemes for adjuvant VBT were 7 Gy × 3 fractions (30%), 5.5 Gy × 5 fractions (26%), and 6 Gy × 5 fractions (28%). The preferred VBT scheme was 5 Gy × 3 fractions (50%) when the external beam radiotherapy (EBRT) dose was 45 Gy external radiotherapy, while the preferred schemes were 6 Gy × 3 fractions (30%) or 5 Gy × 3 fractions (32%) when the external radiotherapy dose was increased to 50.4 Gy. One-half of the respondents delivered VBT twice a week, and the dose was prescribed to 0.5 cm from vaginal mucosa by 86% of the respondents. There was no common definition for the dose prescription length, which was defined as 3 cm from the vaginal cuff in 33% of responses and as 4 cm in 35% of responses. For serous and clear cell histological types, 38% of the respondents targeted "full cylinder length". To prevent vaginal side effects, 78% of the respondents recommended using a vaginal dilator and/or sexual intercourse after VBT. Conclusions This survey revealed variations in the clinical practice of VBT among Turkish radiation oncologists, which suggests that standardization is necessary.
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22
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Impact of CT-based planning and bladder volume changes on the dosimetry of vaginal vault brachytherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396920001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Aim:
To compare dose to target and organs at risk (OARs) in conventional plan (2D) versus computed tomography (CT)-based three-dimensional (3D) plan in vaginal cuff brachytherapy (VBT) and to compare the effect of bladder distension on target and OARs dosimetry.
Materials and methods:
Post-hysterectomy patients with an indication for VBT were included in the study. All patients underwent planning CT scans with a full bladder and an empty bladder protocol. For each CT, two plans were generated—one library-based 2D plan and another CT-based 3D plan. Dosimetric parameters were recorded for clinical target volume (CTV) and OARs.
Results:
A total of 92 observations were made from data collected from 46 patients. Difference between CTV dose in terms of 2D and 3D plans were not statistically significant for CTV (p = 0·11). Significant reduction in D0·1cc, D1cc and D2cc dose parameters were observed in bladder, rectum, sigmoid and bowel doses with the 3D plan (p < 0·001). Bladder distension showed a 20% reduction in dose for bowel (p < 0·001). Bladder distension also showed a 6·12% (p = 0·047) increase in D2cc, but there was a significant reduction in the mean dose to the bladder.
Conclusion:
Our study demonstrates the dosimetric benefits with 3D CT-based planning for VBT over 2D-based conventional planning and benefit of bladder distension in the reduction of bowel dose without compromising dose to the target volume.
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Gultekin M, Yilmaz MT, Biltekin F, Yuce D, Sari SY, Akyol F, Yildiz F. Adjuvant vaginal cuff brachytherapy: dosimetric comparison of conventional versus 3-dimensional planning in endometrial cancer. J Contemp Brachytherapy 2020; 12:601-605. [PMID: 33437309 PMCID: PMC7787204 DOI: 10.5114/jcb.2020.101694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/01/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To evaluate dosimetric differences between point-based 2-dimensional (2D) vaginal brachytherapy (VBT) treatment planning technique and volume-based 3-dimensional (3D) VBT method for endometrial cancer (EC). MATERIAL AND METHODS Ten patients with uterine-confined EC treated with VBT were included in this study. All patients received 27.5 Gy in 5 fractions. Three different treatment plans were performed for each patient: plan A for dose prescribed to the entire vaginal wall thickness delineated via computed tomography guidance, plan B for dose prescribed to the vaginal mucosa/cylinder surface, and plan C for dose prescribed to 5 mm beyond the vaginal mucosa/cylinder surface. Dose-volume histograms (DVH) of treatment volumes and organs at risk (OARs) were evaluated and compared. RESULTS DVH analysis of target volume doses (D100, D95, and D90) showed a significant difference between plan A and plan B (p = 0.005), and plan B was found lower. D100 for plan C was significantly higher than plan A (p = 0.009), but for D95 and D90, no statistically significant difference was found (p = 0.028 and p = 0.028, respectively). In terms of OARs doses, including vagina, rectum, bladder, and sigmoid, D2cm3 doses were significantly higher in plan A than plan B (p = 0.009, p = 0.009, p = 0.005, and p = 0.005, respectively). All these doses were also significantly lower than in plan C (p = 0.005, p = 0.012, and p = 0.013, respectively), except for sigmoid (p = 0.155). CONCLUSIONS In this dosimetric analysis, we have shown that the volume-based 3D VBT technique provides the ability to balance the target dose against the sparing of OARs. Therefore, in the new modern 3D treatment era, instead of normalization of the dose to standard reference points, customized 3D volume-based VBT planning should be recommended.
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Affiliation(s)
- Melis Gultekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Melek Tugce Yilmaz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Fatih Biltekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Deniz Yuce
- Department of Preventive Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sezin Yuce Sari
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Fadil Akyol
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ferah Yildiz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Sarria GR, Sperk E, Wenz F, Schneider F, Abo-Madyan Y, Giordano FA, Ehmann M. Adjuvant electronic brachytherapy for endometrial carcinoma: A 4-year outcomes report. Brachytherapy 2020; 19:635-641. [PMID: 32651094 DOI: 10.1016/j.brachy.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of the study was to report the outcomes of a single-center adjuvant electronic brachytherapy (e-BT) experience for patients with endometrial carcinoma. METHODS AND MATERIALS Patients were retrospectively assessed. Intracavitary e-BT was applied through a cylindrical applicator (diameters 2.5-3.5 cm). e-BT single doses ranged between 4 and 7 Gy (EQD2 ∼ 6-12, α/β of 10 Gy and an relative biological effectiveness of 1.3) at 5-mm depth. Adverse events are reported at first week, 1-3 months, 3-12 months, 12-24 months, and >24 months. The overall survival, disease-free survival, distant disease control rate, and local control rate were estimated using the Kaplan-Meier method. RESULTS Twenty-nine patients were assessed. The median age was 68 [48-86] years. External beam radiotherapy was added in n = 8 (27.6%) patients. Staging was 13.8% for T1a, 51.7% for T1b, 24.1% for T2, 6.9% for T3a, and 3.4% for T3b. Grading was G3 in 51.7% (n = 15), G2 in 20.7% (n = 6), and G1 in 27.6% (n = 8). Median followup was 47 months [5-88]. Overall Grade 1, 2, and 3 toxicity was 89.7% (n = 26), 17.2% (n = 5), and 6.9% (n = 2), respectively. No Grade 3 cystitis or proctitis or any Grade 4 or 5 toxicity occurred during followup. No local recurrences were detected. Estimated distant disease control rate was 92.1% (n = 2, distant metastasis at 7 and 11 months). Estimated 4-year overall survival was 84.8% (n = 4 events, two unrelated to disease) and disease-free survival was 84.6%. CONCLUSIONS Our data suggest that e-BT resembles a very-low-toxicity profile and a high local control rate in the adjuvant scenario for patients with endometrial carcinoma.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, Medical Faculty Freiburg, Freiburg University, Freiburg, Germany
| | - Frank Schneider
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany.
| | - Michael Ehmann
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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van den Akker MJE, Horeweg N, Beltman JJ, Creutzberg CL, Nout RA. Efficacy and toxicity of postoperative external beam radiotherapy or chemoradiation for early-stage cervical cancer. Int J Gynecol Cancer 2020; 30:1878-1886. [PMID: 32591371 DOI: 10.1136/ijgc-2019-001131] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the impact of the evolving role of the addition of chemotherapy to postoperative radiotherapy on oncological outcomes and toxicity in patients with early-stage cervical cancer after radical hysterectomy. METHODS Retrospective cohort study of patients with stage IB1-IIB FIGO 2009 cervical cancer treated from November 1999 to May 2015 by primary surgery and radiotherapy (46-50.4 Gy in 1.8-2.0 Gy fractions) with or without concurrent cisplatin (40 mg/m2, 5-6 weekly cycles) with or without a brachytherapy boost. Chemotherapy was allocated depending on the risk factors for recurrence. Incidences of all outcomes were calculated using Kaplan-Meier's methodology and compared by log-rank tests. Risk factors for recurrence and survival were identified using Cox's proportional hazards models. RESULTS A total of 154 patients were included, median follow-up was 9.6 years (IQR: 6.1-12.8). Five-year pelvic recurrence-free survival was 75.3%; 74.7% in patients with high-risk factors treated with radiotherapy; and 77.3% in those treated with chemoradiation (P=0.43). Distant metastasis-free survival at 5 years was 63.4%; 63.6% in high-risk patients after radiotherapy; and 57.1% after chemoradiation (P=0.36). Five-year overall survival was 63.9%: 66.8% and 51.6% after radiotherapy and after chemoradiation in patients with high-risk factors (P=0.37), respectively. Large tumor size was a risk factor for vaginal and pelvic recurrence, ≥2 involved lymph nodes was a significant risk factor for para-aortic recurrence and death. Mild treatment-related late toxicity was observed in 53.9% of the patients. Five-year severe (grade 3-5) late rectal, bladder, bowel, and vaginal toxicities were, respectively, 1.3%, 0%, 3.4%, and 0.9%. Any late severe toxicity was observed in 5.5% of patients treated with radiotherapy and in 15.3% of those treated with chemoradiation (P=0.07). CONCLUSION Postoperative (chemo)radiation for early-stage cervical cancer patients with risk factors for recurrence yields adequate pelvic tumor control, but overall survival is limited due to distant metastasis.
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Affiliation(s)
- Mick J E van den Akker
- Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.,Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nanda Horeweg
- Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Carien L Creutzberg
- Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Remi A Nout
- Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Outcomes of intermediate-risk to high-risk stage I endometrial cancer: 10-year clinical experiences of using in-house multi-channel applicators in a single center. Chin Med J (Engl) 2020; 132:1935-1941. [PMID: 31365429 PMCID: PMC6708688 DOI: 10.1097/cm9.0000000000000382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are only very few reports on clinical outcomes using multi-channel applicators (MCA) for patients with endometrial cancer (EC) in China. We aimed to evaluate the clinical experience of treating intermediate-risk (IR) to high-risk (HR) stage I EC using in-house made multi-channel applicators (IH-MCA) in a single institution. METHODS Three hundred and ninety patients with stage I IR to HR EC were treated with hysterectomy and adjuvant radiotherapy from 2003 to 2015. All patients received post-operative vaginal cuff brachytherapy (VBT) alone or as a boost after external beam radiotherapy (EBRT). The prescriptions were 500 cGy per fraction for a total of 5 to 6 fractions with brachytherapy alone or 400 to 600 cGy per fraction for 2 to 3 fractions if it was combined with EBRT. Two types of applicators including a traditional rigid IH-MCA and a recent model custom-made with 3 dimension printing technology were used for treatment. The Kaplan-Meier method was used to calculate survival rate. RESULTS Follow-up rate was 92.8% and the median follow-up time was 48 months (range 4-172 months). The 5-year overall survival (OS), progression-free survival, local recurrence, and distant metastasis rates for all patients were 96.3%, 92.1%, 2.9%, and 4.8% respectively. Two patients had isolated relapse in vagina outside the irradiated volume. The univariate and multivariate analysis showed that age and grade were the prognostic factors correlated with OS (hazard ratio: 0.368, 95% confidence interval [CI]: 0.131-1.035, P = 0.048; hazard ratio: 0.576, 95% CI: 0.347-0.958, P = 0.026,). CONCLUSIONS For patients with IR to HR stage I EC, adjuvant VBT alone or in combination with EBRT using IH-MCA led to excellent survival and recurrence rates. Age and grade were the prognostic factors correlated with OS.
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Zhang Y, Ascaso C, Herreros A, Sánchez J, Del Pino M, Torné A, Li Y, Sabater S, Arenas M, Biete A, Rovirosa Á. Is one brachytherapy fraction of 7 Gy similar to more fractions after external beam irradiation in postoperative endometrial carcinoma? Clin Transl Oncol 2019; 22:1295-1302. [PMID: 31865604 DOI: 10.1007/s12094-019-02255-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To determine whether brachytherapy with a single hypofractionated dose of 7 Gy provides the similar vaginal-cuff relapses and safety profile in terms of complications compared to schedules of 2 or 3 fractions of lower doses in patients treated previously with external beam irradiation in postoperative endometrial carcinoma. METHODS/MATERIAL From June 2003 to December 2016, 325 patients were treated with 3 different schedules of high-dose-rate brachytherapy after external beam irradiation for postoperative endometrial carcinoma. The patients were divided into 3 groups: Group-1: 125 patients were treated with 3 fractions of 4-6 Gy per fraction (3 fractions/week) between 2003 and 2008; Group-2: 93 patients were treated with 2 consecutive daily fractions of 5-6 Gy between 2008 and 2011; Group-3: 107 patients received a single fraction of 7 Gy between 2011 and 2016. Bladder and rectum complications were assessed using RTOG scores and with the objective scores of LENT-SOMA for the vagina. STATISTICS the chi-square test. RESULTS The mean follow-up of Groups 1, 2 and 3 was 95, 67 and 51 months, respectively. Three patients in Group-1, 2 in Group-2, 1 in Group-3 developed vaginal-cuff relapse (p = 0.68). No differences were found in late toxicity among the three groups. CONCLUSIONS One single dose of 7 Gy is safe and effective and may be the best treatment schedule with a similar incidence of vaginal-cuff relapses, complications and patient comfort with less hospital attendance.
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Affiliation(s)
- Y Zhang
- Radiation Oncology Department, Hospital Clinic I Universitari, C/ Villarroel 170, 08036, Barcelona, Spain
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - C Ascaso
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - A Herreros
- Radiation Oncology Department, Hospital Clinic I Universitari, C/ Villarroel 170, 08036, Barcelona, Spain
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - J Sánchez
- Economics Department, Hospital Clinic I Universitari, Barcelona, Spain
| | - M Del Pino
- Gynecological Cancer Unit, Gynecological and Obstetrics Department, Hospital Clinic I Universitari, Barcelona, Spain
| | - A Torné
- Gynecological Cancer Unit, Gynecological and Obstetrics Department, Hospital Clinic I Universitari, Barcelona, Spain
| | - Y Li
- Radiation Oncology Department, Hospital Clinic I Universitari, C/ Villarroel 170, 08036, Barcelona, Spain
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - S Sabater
- Radiation Oncology Department, Hospital General Universitario de Albacete, Albacete, Spain
| | - M Arenas
- Radiation Oncology Department, Hospital San Joan de Reus, Reus, Spain
| | - A Biete
- Radiation Oncology Department, Hospital Clinic I Universitari, C/ Villarroel 170, 08036, Barcelona, Spain
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Á Rovirosa
- Radiation Oncology Department, Hospital Clinic I Universitari, C/ Villarroel 170, 08036, Barcelona, Spain.
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain.
- Gynecological Cancer Unit, Gynecological and Obstetrics Department, Hospital Clinic I Universitari, Barcelona, Spain.
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Clinical Outcome of Exclusively Radiographer-led Delivery of Postoperative Vaginal Vault Brachytherapy for Endometrial Cancer – The Addenbrooke's Experience. Clin Oncol (R Coll Radiol) 2019; 31:844-849. [DOI: 10.1016/j.clon.2019.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/22/2022]
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Alban GM, Buscariollo DL, Cheng T, Pretz J, Krechmer B, Buzurovic I, Singer L, King M, Lee L. Low-Dose Adjuvant Cylinder Brachytherapy for Endometrioid Endometrial Cancer. Pract Radiat Oncol 2019; 10:95-103. [PMID: 31783169 DOI: 10.1016/j.prro.2019.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Our purpose was to evaluate outcomes and sites of failure for women with early stage endometrial adenocarcinoma treated with adjuvant high-dose-rate (HDR) vaginal brachytherapy (VB) with a low dose scheme. METHODS AND MATERIALS Retrospective review identified 318 patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrioid endometrial cancer who received adjuvant HDR VB to a dose of 24 Gray (Gy) in 6 fractions from 2005 to 2017. Patients with <6 months follow-up were excluded. Dose was prescribed to cylinder surface and computerized tomography (CT) imaging was performed before each fraction to assess cylinder placement. Rates of vaginal relapse (VR), pelvic nodal relapse, distant metastasis, recurrence-free survival, and overall survival were calculated by Kaplan-Meier method. Univariate analysis was performed by log rank test or Cox proportional hazards. Pretreatment CT images were analyzed for patients with VR. RESULTS Median follow-up was 42 months for 243 patients. The 3-year rates of VR, pelvic nodal relapse, distant metastasis, recurrence-free survival, and overall survival were 1.9%, 1.5%, 4.3%, 94.1%, and 98.9%, respectively. The 3-year VR rates by Gynecologic Oncology (GOG)-99 risk groups were 0%, 1.4%, and 3.2% for low risk, low-intermediate risk, and high-intermediate risk (HIR) disease (P = .5). By Post-operative Radiation Therapy in Endometrial Carcinoma (PORTEC) risk stratification, 3-year VR rate was 1.3% for HIR disease. On review of pretreatment CT images of the 6 patients with VR, 3 patients had relapse at the introitus outside of the treated vaginal length, and 3 had in-field recurrence at the vaginal apex. Higher body mass index (BMI) was associated with VR, with a 14% increase in risk per BMI unit (kg/m2, P = .02). There were no reported grade 2 GI or any grade 3 toxicities. CONCLUSIONS Adjuvant HDR VB with a low-dose regimen results in excellent clinical outcomes for patients with early stage endometrioid endometrial cancer. Patients with higher BMI may be at increased risk of VR, and additional study is needed to optimize brachytherapy treatment parameters.
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Affiliation(s)
- Gabriela M Alban
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniela L Buscariollo
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Teresa Cheng
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Pretz
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Betty Krechmer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Ivan Buzurovic
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Lisa Singer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Martin King
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Larissa Lee
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
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Onderdonk BE, Wu T, Al-Hallaq H, Son CH, Waller J, Hasan Y. Clinical and Dosimetric Implications of Intrafractional Cylinder Movement During Vaginal Cuff Brachytherapy. Cureus 2019; 11:e6165. [PMID: 31890373 PMCID: PMC6913955 DOI: 10.7759/cureus.6165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction To quantify the dosimetric and clinical effects of intrafractional cylinder movement in patients receiving high-dose-rate vaginal cuff brachytherapy (VBT) without a formal immobilization device and the implication of motion on institutional clinical outcomes. Methods From 2013-2018, 119 patients were treated with VBT with no formal immobilization device at a single institution. As a quality assessment study, pre-and post-cylinder brachytherapy kilovoltage (kV) images were acquired for 37 fractions in nine consecutive patients who underwent VBT and clinical care representative of institutional practice standards. The D90 and D90 EqD2 were calculated according to each patient's average intrafractional movement throughout the treatment course. The D2cc for organs-at-risk (OARs) were also re-evaluated following the simulated movements. The survival outcomes and toxicity were recorded from the 119 patients. Toxicity was graded as per Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Results The measured mean ± standard deviation movement was 5.0 mm ± 3.5, with 62% moving caudad. The D90 from each patient's maximum and average movements were lower than the pre-planned doses: 71%, and 89%, respectively. The doses to the OARs were lower than the pre-planned doses. After a median follow-up of 20 months, there were three local recurrences with a median time of 14.5 months (range: 10-31). There were two acute grade 3+ toxicities and one late grade 3+ toxicity. There was a moderate correlation (r = 0.40) between body mass index (BMI) and intrafraction movement with caudad being more common in smaller BMIs (p = 0.0216). Conclusions Intrafractional vaginal cylinder movement without a table fixation device is about 5.0 mm, with the majority of movements moving caudad. While institutional outcomes suggest that local control may not be compromised, consideration of more formal immobilization devices is warranted, especially for those patients with lower BMIs.
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Affiliation(s)
- Benjamin E Onderdonk
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Tianming Wu
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Hania Al-Hallaq
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Christina H Son
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Joseph Waller
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, USA
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Zhang Y, Rovirosa A, Ascaso C, Herreros A, Torne A, Li Y, Biete A, Sánchez J. Economic impact of decreasing the fraction number in vaginal cuff brachytherapy: A direct cost analysis. Brachytherapy 2019; 19:60-65. [PMID: 31587986 DOI: 10.1016/j.brachy.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/29/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to analyze the direct economic impact of two vaginal cuff brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) with similar vaginal control and toxicity results. MATERIALS AND METHODS From 2006 to 2015, 397 PEC patients (p) were treated with VBT: mean 40p/year, 67.5% received external beam radiotherapy (EBRT)+VBT and 32.5% exclusive VBT. Schedule 1: 3 fractions (Fr) after EBRT and 6Fr (4-6 Gy/Fr) in exclusive VBT. Schedule 2: 7Gy × 1Fr + EBRT and 6Gy × 3Fr in exclusive VBT. Differential cost analysis of the two schedules was retrospectively performed. The direct costs in each schedule were (1) Personnel: radiotherapy technicians, nurses, radiation oncologists, medical physicists, administrative personnel, orderlies; time dedicated by each professional during CT planning acquisitions and delineation of vagina/organs at risk, dosimetric study and evaluation, autoradiography, procedure reporting time during/after treatment, removal of bladder/rectal tubes and applicators, material cleaning and transportation for sterilization; (2) Health care material (gels, gauzes, gloves, etc); (3) Equipment (time equipment used). The differential between the two schedules was estimated. Indirect costs and evaluation of quality of life-adjusted costs were not considered. RESULTS The overall reduction in the number of Fr per year in Schedule 2 was 93. Cost savings included treatment time per year: 4,185 min (70 h); personnel: 221€ ($246)/p in EBRT + VBT and 331€ ($368)/p in exclusive VBT; and health care material and equipment: 40€ ($44.5)/p in EBRT + VBT and 90€ ($100.2)/p in exclusive VBT. The overall savings per patient was 261€ ($295) in combined treatment and 421€ ($475.7) in exclusive VBT. The total savings per year with Schedule 2 in 40p was 12,503€ ($13,915.8). CONCLUSIONS A 41% reduction in the fractions number in VBT for PEC allowed economic savings of 261€ ($290.5)/p in combined treatment and 421€ ($475.7)/p in exclusive VBT. Other benefits include patient comfort and fewer treatment visits.
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Affiliation(s)
- Yaowen Zhang
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Angeles Rovirosa
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain; Gynaecological Cancer Unit, Gynaecology and Obtetrics Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain.
| | - Carlos Ascaso
- Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Antonio Herreros
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Aureli Torne
- Gynaecological Cancer Unit, Gynaecology and Obtetrics Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Yan Li
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Albert Biete
- Fonaments Clinics Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Radiation Oncology Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
| | - Joan Sánchez
- Economics Department, Hospital Clinic Universitari Barcelona, Barcelona, Spain
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Abstract
Brachytherapy involves the placement of radioactive sources within or very close to the tumor. This placement allows a high dose of radiotherapy to be delivered to the tumor while sparing the surrounding normal tissue. The delivery of brachytherapy has changed markedly over the years, with newer radioactive sources making delivery safer, image guidance techniques allowing more accurate placement of sources, and advanced planning systems allowing brachytherapy to be truly adaptive. This article explores the most modern techniques and current uses of brachytherapy in the treatment of gynecological, prostate, breast, rectal, and skin cancers.
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Affiliation(s)
- Sophie J Otter
- Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK.
| | | | - Phillip M Devlin
- Dana Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Guy CL, Fields EC, Quinn BA, Fisher CM, Ladbury CJ, Romano KD, Todor D. The vaginal cylinder: Misunderstood, misused, or trivial? An in-depth dosimetric and multiinstitutional outcome investigation. Brachytherapy 2019; 18:763-770. [PMID: 31558353 DOI: 10.1016/j.brachy.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/06/2019] [Accepted: 08/13/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE The purpose of the study was to investigate the impact on dose distribution and radiobiological metrics of common high-dose-rate vaginal brachytherapy treatment parameters and to analyze multiinstitutional data for clinically significant impact on outcomes in early-stage endometrial cancer. METHODS AND MATERIALS Treatment plans were created for all combinations of prescription parameters and used to quantify the dosimetric impact of each parameter and to estimate the dose delivered using common voxel-integrated radiobiological metrics. A rating system, based on risk grouping from GOG and PORTEC trials, was used to consolidate staging information into a cancer "aggressiveness" measure. Correlations between the rating, toxicity, disease recurrence, and plan parameters were investigated. RESULTS When prescribing to 5 mm depth, the variation caused by the diameter was very large across all dose metrics, ranging from 51% to 175% increase with the most divergence in BEDmax. For surface prescription, changing the cylinder diameter from 4 cm to 2 cm caused the dose metrics of BEDmin, Dmin, and gBEUD (a = -3) to increase by 117%, 67%, and 52%, respectively. Prescription to 5-mm depth caused changes across all dose metrics of 260% compared with surface prescription for a 2-cm cylinder. Deeper prescription point (p = 0.005) and longer treatment length (p = 0.01) were correlated with increased stenosis rates. No correlation between recurrence and any plan parameter was found. CONCLUSIONS Dramatic differences in dose distributions arise by small variations of plan parameters, with large impact on rates of vaginal stenosis, but no clear relation with local recurrence. To help radiation oncologists interpret the magnitude of these effects for their patients, we created a tool that allows comparison between dose and fractionation parameters.
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Affiliation(s)
- Christopher L Guy
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Bridget A Quinn
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | - Colton J Ladbury
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Dorin Todor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Martell K, Doll C, Barnes EA, Phan T, Leung E, Taggar A. Radiotherapy practices in postoperative endometrial cancer: A survey of the ABS membership. Brachytherapy 2019; 18:741-746. [PMID: 31521546 DOI: 10.1016/j.brachy.2019.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/05/2019] [Accepted: 07/22/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE This survey aimed to document the current practice patterns of postoperative radiotherapy (RT), including vaginal vault brachytherapy (VVB) and external beam radiotherapy (EBRT), in the management of patients with endometrial cancer. METHODS AND MATERIALS A 30-item, multiple choice survey querying RT prescribing practices and planning techniques was distributed electronically to American Brachytherapy Society members in December 2018. RESULTS Seventy-five surveys from 62 centers were completed. Eighty-nine percent of respondents practiced within the USA or Canada. Most (79%) respondents indicated a preference for recommending adjuvant VVB alone in FIGO Stage IB, Grade 2 margin and lymphovascular space invasion (LVSI) negative disease. For FIGO Stage IB, Grade 3, LVSI-positive disease, most respondents preferred incorporating EBRT either alone (33%) or with VVB (28%). For IIIC1, margin positive disease, VVB in addition to EBRT was most commonly recommended (75%). When planning adjuvant EBRT, 49% utilized CT simulation with both bladder full and empty. Internal target volume was utilized by 53%. Volumetric modulated arc therapy (53%) or intensity-modulated radiotherapy (19%) were commonly used planning techniques. The most common dose prescription was 45 Gy in 25 fractions (57%). When treating with VVB, 49% determined applicator size at the time of brachytherapy. Sixty-four percent planned treatments based on CT imaging with the applicator in situ and 33% repeated CT imaging before each subsequent fraction. The most common prescription was 21 Gy in three fractions prescribed to 0.5 cm depth (43%). CONCLUSIONS This study identified variability in treatment recommendations and in both EBRT and VVB simulation and planning processes in postoperative endometrial cancer.
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Affiliation(s)
- Kevin Martell
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada.
| | - Corinne Doll
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Elizabeth A Barnes
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tien Phan
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Eric Leung
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amandeep Taggar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Albuquerque K, Hrycushko BA, Harkenrider MM, Mayadev J, Klopp A, Beriwal S, Petereit DG, Scanderbeg DJ, Yashar C. Compendium of fractionation choices for gynecologic HDR brachytherapy—An American Brachytherapy Society Task Group Report. Brachytherapy 2019; 18:429-436. [DOI: 10.1016/j.brachy.2019.02.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/07/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
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Ager BJ, Francis SR, Do OA, Huang YJ, Soisson AP, Dodson MK, Werner TL, Sause WT, Grant JD, Gaffney DK. Do vaginal recurrence rates differ among adjuvant vaginal brachytherapy regimens in early-stage endometrial cancer? Brachytherapy 2019; 18:453-461. [PMID: 31005603 DOI: 10.1016/j.brachy.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE We sought to retrospectively examine clinical outcomes for three adjuvant vaginal high-dose-rate (HDR) brachytherapy regimens after hysterectomy for early-stage endometrial cancer. METHODS Included were women of all ages from two independent hospital systems diagnosed with Stage I-II endometrial cancer of any grade between 2000 and 2016 who underwent hysterectomy followed by adjuvant vaginal cylinder HDR brachytherapy with either 7.0 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, 6.5 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, or 6.0 Gy × 5 fractions prescribed to the vaginal surface. Outcomes included vaginal recurrence (VR), pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival. RESULTS Of the 348 women, 45 (13%) received 7.0 Gy × 3 fractions, 259 (74%) received 6.5 Gy × 3 fractions, and 44 (13%) received 6.0 Gy × 5 fractions. Women receiving 5-fraction brachytherapy were more likely to be younger with a higher performance status. At a median follow-up of 4.5 years, VR rates were 2.2%, 0.8%, and 4.5%, respectively. Multivariate analysis revealed no significant differences in the risks for VR among brachytherapy regimens. Risks for VR, pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival did not differ between propensity score-matched five- and 3-fraction brachytherapy cohorts. CONCLUSIONS VR rates after hysterectomy and adjuvant vaginal brachytherapy for early-stage endometrial cancer were low and not significantly different by HDR dose fractionation.
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Affiliation(s)
- Bryan J Ager
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Samual R Francis
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Olivia A Do
- Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Andrew P Soisson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mark K Dodson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Theresa L Werner
- Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - William T Sause
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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Hentz C, McAlarnen L, Harkenrider M, Small W. Radiation Therapy in Endometrial Cancer. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_56-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Cost in perspective: direct assessment of American market acceptability of Co-60 in gynecologic high-dose-rate brachytherapy and contrast with experience abroad. J Contemp Brachytherapy 2018; 10:503-509. [PMID: 30662472 PMCID: PMC6335552 DOI: 10.5114/jcb.2018.79928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/03/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose While Ir-192 remains the mainstay isotope for gynecologic high-dose-rate (HDR) brachytherapy in the U.S., Co-60 is used abroad. Co-60 has a longer half-life than Ir-192, which may lead to long-term cost savings; however, its higher energy requires greater shielding. This study analyzes Co-60 acceptability based on a one-time expense of additional shielding and reports the financial experience of Co-60 in Peru’s National Cancer Institute, which uses both isotopes. Material and methods A nationwide survey was undertaken assessing physician knowledge of Co-60 and willingness-to-pay (WTP) for additional shielding, assuming a source more cost-effective than Ir-192 was available. With 440 respondents, 280 clinicians were decision-makers and provided WTPs, with results previously reported. After completing a shielding report, we estimated costs for shielding expansion, noting acceptability to decision makers’ WTP. Using activity-based costing, we note the Peruvian fiscal experience. Results Shielding estimates ranged from $173,000 to $418,000. The percentage of respondents accepting high-density modular or lead shielding (for union and non-union settings) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Shielding acceptance was associated with greater number of radiation oncologists in a respondent’s department but not time in practice or the American Brachytherapy Society membership. Peru’s experience noted cost savings with Co-60 of $52,400 annually. Conclusions By comparing the cost of additional shielding for a sample institution’s HDR suite with radiation oncologists’ WTP, this multi-institutional collaboration noted < 20% of clinicians would accept additional shielding. Despite low acceptability in the US, Co-60 demonstrates cost-favorability in Peru and may similarly in other locations.
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Nieto K, Martin B, Pham N, Palmere L, Silva SR, Winder A, Liotta M, Potkul RK, Small W, Harkenrider MM. Does adjuvant concurrent or sequential chemotherapy increase the radiation-related toxicity of vaginal brachytherapy for endometrial cancer patients? Brachytherapy 2018; 17:929-934. [PMID: 30227976 DOI: 10.1016/j.brachy.2018.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/20/2018] [Accepted: 08/08/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare radiation toxicity in endometrial cancer patients treated with adjuvant vaginal brachytherapy (VBT) vs. VBT with concurrent chemotherapy (CCT) or sequential chemotherapy (SCT) METHODS: We retrospectively analyzed 131 patients with endometrial cancer treated with VBT without external beam radiation therapy. Toxicities were graded according to the Common Terminology Criteria for Adverse Events v4.03. CCT was defined as VBT delivered between the first and last cycle of chemotherapy (CT); SCT was defined as VBT delivered before or after CT. RESULTS Median followup was 36 months, with a 3-year survival rate of 88%. Of the 131 patients, 92 were treated with VBT alone, 34 with VBT and CCT, and 5 with VBT and SCT. The most common toxicity was vaginal stricture, with 30 (22.9%) patients affected. The distribution of toxicities was vaginal 28%, urinary 12%, rectal 11%, and fatigue 5%; none greater than Grade 2. Compared with patients treated with VBT alone, the addition of CT did not increase the chance of vaginal stricture formation (p = 0.84). The difference in system-specific toxicities between treatment modalities was not statistically significant. CONCLUSION The most common pelvic toxicity from VBT is vaginal stenosis with other toxicities being infrequent and generally Grade 1. The addition of CT in a sequential or concurrent fashion did not increase the rate of pelvic toxicity from VBT alone.
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Affiliation(s)
- Karina Nieto
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Brendan Martin
- Clinical Research Office, Loyola University Chicago Health Sciences Division, Chicago, IL
| | - Nghia Pham
- Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Laura Palmere
- Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Scott R Silva
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Abigail Winder
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Margaret Liotta
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Ronald K Potkul
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL.
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Stahl JM, Qian JM, Tien CJ, Carlson DJ, Chen Z, Ratner ES, Park HS, Damast S. Extended duration of dilator use beyond 1 year may reduce vaginal stenosis after intravaginal high-dose-rate brachytherapy. Support Care Cancer 2018; 27:1425-1433. [PMID: 30187220 DOI: 10.1007/s00520-018-4441-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vaginal dilators (VD) are recommended following vaginal or pelvic radiotherapy for patients with endometrial carcinoma (EC) to prevent vaginal stenosis (VS). The time course of VS is not fully understood and the optimal duration of VD use is unknown. METHODS We reviewed 243 stage IA-II EC patients who received adjuvant brachytherapy (BT) at an academic tertiary referral center. Patients were instructed to use their VD three times per week for at least 1-year duration. The primary outcome was development of grade ≥ 1 VS using CTCAEv4 criteria during the follow-up period. The log-rank test and multivariable Cox proportional hazards modeling were used to evaluate the effect of VD use (noncompliance vs. standard compliance [up to 1 year] vs. extended compliance [over 1 year]) on VS. RESULTS The median follow-up was 15.2 months over the 5-year study period. At 15 months, the incidence of VS was 38.8% for noncompliant patients, 33.5% for those with standard compliance, and 21.4% for those with extended compliance (median time to grade ≥ 1 VS was 17.5 months, 26.7 months, and not yet reached for these groups, respectively). On multivariable Cox regression analysis, extended compliance remained a significant predictor of reduced VS risk when compared to both noncompliance (HR 0.38, 95% CI 0.18-0.80, p = 0.012) and standard compliance (HR 0.43, 95% CI 0.20-0.89, p = 0.023). CONCLUSIONS The risk of VS persists beyond 1 year after BT. Extended VD compliance beyond 1 year may mitigate this risk.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.
| | - Jack M Qian
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J Tien
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Zhe Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Elena S Ratner
- Department of Gynecology and Reproductive Sciences, Section of Gynecologic Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
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Harkenrider MM, Martin B, Nieto K, Small C, Aref I, Bergman D, Chundury A, Elshaikh MA, Gaffney D, Jhingran A, Lee L, Paydar I, Ra K, Schwarz J, Thorpe C, Viswanathan AN, Small W. Multi-institutional Analysis of Vaginal Brachytherapy Alone for Women With Stage II Endometrial Carcinoma. Int J Radiat Oncol Biol Phys 2018; 101:1069-1077. [DOI: 10.1016/j.ijrobp.2018.04.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/06/2018] [Accepted: 04/17/2018] [Indexed: 11/30/2022]
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42
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Kharouta MZ, Pham N, Nieto K, Surucu M, Mysz ML, Albuquerque K, Winder A, Liotta M, Potkul RK, Small W, Harkenrider MM. Comparison of dosimetric and clinical outcomes between short- and long-channel cylinder applicators for vaginal brachytherapy in intermediate- and high-risk endometrial cancer. Brachytherapy 2018; 17:673-679. [DOI: 10.1016/j.brachy.2018.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/12/2018] [Accepted: 04/07/2018] [Indexed: 10/16/2022]
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43
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The impact of adjuvant vaginal brachytherapy in women with Stage II uterine endometrioid carcinoma: Results of a National Cancer Database analysis. Brachytherapy 2018; 17:319-325. [DOI: 10.1016/j.brachy.2017.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/04/2017] [Accepted: 10/23/2017] [Indexed: 11/23/2022]
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44
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Sabater S, Andres I, Lopez-Honrubia V, Berenguer R, Sevillano M, Jimenez-Jimenez E, Rovirosa A, Arenas M. Vaginal cuff brachytherapy in endometrial cancer - a technically easy treatment? Cancer Manag Res 2017; 9:351-362. [PMID: 28848362 PMCID: PMC5557121 DOI: 10.2147/cmar.s119125] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.
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Affiliation(s)
- Sebastià Sabater
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Ignacio Andres
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | - Roberto Berenguer
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Marimar Sevillano
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | | | - Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan, Reus, Spain
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45
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Rovirosa Á, Herreros A, Camacho C, Ascaso C, Sánchez J, Cortés S, Sabater S, Solà J, Torné A, Arenas M. Comparative results of three short brachytherapy schedules as exclusive treatment in postoperative endometrial carcinoma. Brachytherapy 2017; 16:1169-1174. [PMID: 28801116 DOI: 10.1016/j.brachy.2017.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/01/2017] [Accepted: 07/05/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE To compare vaginal control and treatment toxicity of three different high-dose-rate brachytherapy schedules as exclusive treatment in postoperative endometrial carcinoma. METHODS AND MATERIALS From 2003 to 2015, three different schedules were used as postoperative treatment for 146 patients (p) with intermediate-risk endometrial carcinoma. Group 1 (41 p): six fractions of 4-6 Gy, 3-4 fractions per week; Group 2 (59 p): four fractions of 5-6 Gy administered daily; Group 3 (46 p): 6 Gy × 3 fractions in three consecutive days. The dose was prescribed at 5 mm of applicator surface using an active treatment length of 2.5 cm. Toxicity scores were evaluated using the Radiation Therapy Oncology Group scores for bladder and rectum and the objective criteria of late effects of normal tissues-subjective, objective, management, analytic for vagina. Statistics used were group descriptions calculating their means, medians, and ranges. Bivariate analysis was evaluated using variance models and χ2 tests. RESULTS The mean followup was as follows: Group 1: 88 months, Group 2: 75 months, and 41 months in Group 3. No vaginal relapses were found. Late toxicity ≥ G2: rectum: 0 p in the three groups (0%). Bladder: Group 1: 1 p (2.4%), Group 2: 0%, and Group 3: 0%. Vagina: Group 1: 4 p (9.5%); Group 2: 9 p (15.3%); and Group 3:10 p (21.8%). There were no differences in late toxicity among the three groups of patients for rectum (p = 0.83), bladder (p = 0.58), and vagina (p = 0.67); the expected global risk of complications for rectum, bladder, and vagina is 0.8%, 0.8%, and 28.8%, respectively. CONCLUSIONS Similar results in vaginal control and complications were achieved with the three schedules. The use of three fractions of 6 Gy administered daily is the best option for patient comfort and convenience and use of resources. Nonetheless, specific studies are needed to demonstrate the best cost-efficacy regime.
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Affiliation(s)
- Ángeles Rovirosa
- Radiation Oncology Department, Hospital Clínic i Universitari, Barcelona, Spain; Gynecological Cancer Unit, Hospital Clínic i Universitari, Barcelona, Spain.
| | - Antonio Herreros
- Radiation Oncology Department, Hospital Clínic i Universitari, Barcelona, Spain
| | - Cristina Camacho
- Radiation Oncology Department, Hospital Clínic i Universitari, Barcelona, Spain
| | - Carlos Ascaso
- Basic Clinic Practice Department, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Joan Sánchez
- Economics Department, Hospital Clínic i Universitari, Barcelona, Spain
| | - Stepphania Cortés
- Radiation Oncology Department, Hospital Clínic i Universitari, Barcelona, Spain
| | - Sebastià Sabater
- Radiation Oncology Department, Hospital General de Albacete, Albacete, Spain
| | - Jordi Solà
- Radiation Oncology Department, Hospital Clínic i Universitari, Barcelona, Spain
| | - Aureli Torné
- Gynecological Cancer Unit, Hospital Clínic i Universitari, Barcelona, Spain
| | - Meritxell Arenas
- Radiation Oncology Department, Hospital Sant Joan de Reus, Reus, Spain
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46
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Mailhot Vega R, Talcott W, Ishaq O, Cohen P, Small CJ, Duckworth T, Sarria Bardales G, Perez CA, Schiff PB, Small W, Harkenrider MM. A national survey of HDR source knowledge among practicing radiation oncologists and residents: Establishing a willingness-to-pay threshold for cobalt-60 usage. Brachytherapy 2017; 16:910-915. [DOI: 10.1016/j.brachy.2017.04.235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/23/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
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47
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Modh A, Burmeister C, Munkarah AR, Elshaikh MA. External pelvic and vaginal irradiation vs. vaginal irradiation alone as postoperative therapy in women with early stage uterine serous carcinoma: Results of a National Cancer Database analysis. Brachytherapy 2017; 16:841-846. [PMID: 28511891 DOI: 10.1016/j.brachy.2017.04.237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/09/2017] [Accepted: 04/06/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Adjuvant treatment in early stage uterine serous carcinoma (USC) usually consists of chemotherapy with vaginal brachytherapy (VB), pelvic external beam radiation therapy (EBRT), or combination. We compared survival outcomes across these various radiation treatment modalities using the National Cancer Database. METHODS AND MATERIALS The National Cancer Database was queried for adult females with histologically confirmed International Federation of Gynecology and Obstetrics 1988 Stage I-II USC diagnosed from 2003 to 2013 treated definitively with hysterectomy, adjuvant chemotherapy, and radiation therapy. χ2 tests were used to assess differences by radiation type (VB, pelvic EBRT, and EBRT + VB) and various clinical variables. Kaplan-Meier and log-rank test methods were used to evaluate survival outcomes. Risk factors related to overall survival were identified by univariate and multivariate analysis. RESULTS We identified 1336 patients with USC who met our inclusion criteria. Most patients were treated with VB (66%) compared with EBRT (21%) or combination EBRT + VB (13%). The proportion of patients who received EBRT (including EBRT + VB) was higher for those who did not have a lymph node dissection or with fewer dissected lymph nodes. Patients treated with VB alone had longer 5-year survival rates (84% [95% confidence interval: 80, 90]) than those treated with EBRT (75% [95% confidence interval: 69, 80]) (p < 0.001). On multivariate analysis, the presence of lymphovascular space invasion (hazard ratio, 2.48; p < 0.001) and the absence of a lymph node dissection (hazard ratio, 2.24; p = 0.047) were independent predictors of overall survival. CONCLUSIONS This large hospital-based study suggests that VB alone may be sufficient for adjuvant radiation treatment in women with USC treated with adjuvant chemotherapy and who underwent an adequate surgical staging.
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Affiliation(s)
- Ankit Modh
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI
| | | | - Adnan R Munkarah
- Division of Gynecologic Oncology, Department of Women's Health Services, Henry Ford Hospital, Detroit, MI
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48
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Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, Viswanathan AN, Small W. American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review. Brachytherapy 2017; 16:95-108. [PMID: 27260082 PMCID: PMC5612425 DOI: 10.1016/j.brachy.2016.04.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/30/2016] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
This article aims to review the risk stratification of endometrial cancer, treatment rationale, outcomes, treatment planning, and treatment recommendations of vaginal brachytherapy (VBT) in the postoperative management of endometrial cancer patients. The authors performed a thorough review of the literature and reference pertinent articles pertaining to the aims of this review. Adjuvant VBT for early-stage endometrial cancer patients results in very low rates of vaginal recurrence (0-3.1%) with low rates of late toxicity which are primarily vaginal in nature. Post-Operative Radiation Therapy in Endometrial Cancer 2 (PORTEC-2) supports that VBT results in noninferior rates of vaginal recurrence compared to external beam radiotherapy for the treatment of high-intermediate risk patients. VBT as a boost after external beam radiotherapy, in combination with chemotherapy, and for high-risk histologies have shown excellent results as well though randomized data do not exist supporting VBT boost. There are many different applicators, dose-fractionation schedules, and treatment planning techniques which all result in favorable clinical outcomes and low rates of toxicity. Recommendations have been published by the American Brachytherapy Society and the American Society of Radiation Oncology to help guide practitioners in the use of VBT. Data support that patients and physicians prefer joint decision making regarding the use of VBT, and patients often desire additional treatment for a marginal benefit in risk of recurrence. Discussions regarding adjuvant therapy for endometrial cancer are best performed in a multidisciplinary setting, and patients should be counseled properly regarding the risks and benefits of adjuvant therapy.
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MESH Headings
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/radiotherapy
- Advisory Committees
- Brachytherapy/methods
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/radiotherapy
- Carcinosarcoma/pathology
- Carcinosarcoma/radiotherapy
- Combined Modality Therapy
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/radiotherapy
- Female
- Humans
- Hysterectomy
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/radiotherapy
- Radiotherapy, Adjuvant/methods
- Societies, Medical
- United States
- Vagina
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL.
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ellen Jones
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
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49
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A new short daily brachytherapy schedule in postoperative endometrial carcinoma. Preliminary results. Brachytherapy 2016; 16:147-152. [PMID: 28029590 DOI: 10.1016/j.brachy.2016.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the preliminary results of vaginal-cuff relapses (VCR) and complications of a short brachytherapy (BT) schedule in postoperative endometrial carcinoma. METHODS AND MATERIALS From September 2011 to December 2014, 102 patients were treated with postoperative BT for endometrial carcinoma. Seventy-four patients received a single 7 Gy dose after external beam irradiation (Group 1), and 28 intermediate-risk patients received three daily fractions of 6 Gy (Group 2). The dose was prescribed at 5 mm from the applicator surface. Toxicity was prospectively evaluated after the objective late effects of normal tissues-subjective, objective, management, analytic scores for vagina and RTOG scores for rectum and bladder. STATISTICS χ2 and Student's t tests. RESULTS The mean followup was 28.85 months (9.6-58.5) in Group 1 and 31.19 months (7.7-62.3) in Group 2. No VCR was found during followup. Late toxicity: vagina toxicity was developed in 24.32% of the patients in Group 1 (G1-G2) and in 21.4% in Group 2 (G1-G2 but 1 G3). Rectal toxicity appeared in only 2.7% of patients in Group 1 (G1). Neither Group 1 nor Group 2 presented late bladder toxicity. No differences were found in late toxicity between Groups 1 and 2. CONCLUSIONS The present short BT schedule was safe in relation to VCR and late toxicity for the followup period studied. These results are similar to those of two larger previous schedules performed in our center in relation to the same point of followup.
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50
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Modh A, Ghanem AI, Burmeister C, Rasool N, Elshaikh MA. Trends in the utilization of adjuvant vaginal brachytherapy in women with early-stage endometrial carcinoma: Results of an updated period analysis of SEER data. Brachytherapy 2016; 15:554-61. [PMID: 27475480 DOI: 10.1016/j.brachy.2016.06.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/14/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Adjuvant vaginal brachytherapy (VB) is a well-established and effective radiation treatment modality in women with early-stage endometrial carcinoma. We sought to evaluate and update published trends in the utilization of VB vs. other radiation therapy modalities (pelvic external beam radiation therapy (EBRT) or the combination of VB and pelvic EBRT using the National Cancer Institute's Surveillance, Epidemiology, and End Results database. METHODS AND MATERIALS The Surveillance, Epidemiology, and End Results database was queried for adult females with histologically confirmed International Federation of Gynecology and Obstetrics 1988 Stage I-II endometrial carcinoma diagnosed from 1995 to 2012 and treated definitively with hysterectomy and adjuvant radiation therapy. Chi-square tests were used to assess differences by radiation type (VB, EBRT, and VB + EBRT) and various demographic and clinical variables. RESULTS We identified 15,201 patients that met inclusion criteria. There was a significant overall increase in the use of VB was observed from 17.1% in 1995-2000 compared to 57.1% in 2007-2012 (p < 0.0001). Similarly, there was a proportional decrease in the use of EBRT from 54.0% to 25.5% (p < 0.0001) as well as in the use of VB + EBRT from 28.9% to 17.4% during the same period (p < 0.0001). The observed increase in utilization of VB was not limited to any variables (age, race, histological type, International Federation of Gynecology and Obstetrics stage, and the status of lymph node dissection [yes or no]) or the number of dissected lymph nodes. CONCLUSIONS In this large national database set, there continues to be an increasing trend for the use of VB in the adjuvant setting in women with early-stage endometrial carcinoma.
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Affiliation(s)
- Ankit Modh
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI
| | - Ahmed I Ghanem
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI
| | | | - Nabila Rasool
- Division of Gynecologic Oncology, Department of Women's Health Services, Henry Ford Hospital, Detroit, MI
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